Having developed a Graded Hierarchy, the keyworker prepares the young person for taking each step at a time. Use of ABC Diary-keeping, Rating Scales and relaxation techniques such as Progressive Muscle Relaxation will help to frame this work.

The basic theory is that anxiety tends to encourage avoidance, and that avoidance side-steps any testing of the beliefs (a kind of Pretend mode coupled with Psychic equivalence ("I'll just DIE if I start blushing in front of that shopkeeper!") - Graded Exposure works because anxiety natrually tends to REDUCE with time (your body cannot make adrenaline indefinitely.)

Key tasks are to avoid the temptation to skip steps (risking the young person being overwhelmed and subsequently discouraged) - try to maintain a steady course up the steps which should be basically achievable.

Each step up the hierarchy should be repeated enough times to allow the Rating Scales score at its peak to reduce, so that ultimately it is not substantially raised when the young person is exposed to the feared stimulus.

• Remember the PsychoEducation that precedes this work - you are emphasising that some anxiety is a natural phenomenon, and not something to be feared.
• Remember too that part of the exercise is about the deliberate provocation of small "doses" of anxiety, so as to allow the young person to test out his or her new found skills in managing anxiety (Progressive Muscle Relaxation, etc) - this is ultimately designed to promote Self-efficacy.

Trauma (Narrative)-focussed Exposure:

In Trauma-focussed work Graded Exposure is used, but in a slightly different way, in that the 'feared stimulus' is a memory rather than a place or a thing (although there are often also places and things that a sufferer of PTSD will fear and avoid, too.)

The technique here is (again, following careful preparatory work - see Trauma-focussed CBT) to invite the young person to start to tell the story of the trauma, after first using Rating Scales.

As the young person tells the story of the trauma, the worker may occasionally need to support them - particularly if they are distressed. At these points re-visiting the Rating Scales is helpful, and using an exercise like Progressive Muscle Relaxation or Re-breathing may be required - but the focus is on getting to the end of the story of the trauma.

During the telling, "hot-spots" may become apparent, where the young person tends to skip details, or becomes obviously flustered or panicky. Gentle, curious questioning may help to clarify details of these areas of experience, but this may only emerge after numerous tellings and retellings.

The Telling and re-telling of the story is a key part of the "Exposure" - this means that immediately they have finished the story, the worker literally asks the young person to

"Please go back to the beginning again and tell me the story again"

The worker is relying on the fact that ANXIETY CANNOT REMAIN ELEVATED INDEFINITELY - adrenaline simply runs out! As the anxiety levels reduce the young person is more able to think, and in due course to re-construct a story that reduces the GUILT, SELF-BLAME, the SENSE OF POWERLESSNESS, and some of the NEGATIVE STATEMENTS about the self that may have arisen from these overwhelming experiences. Weighing Pros and Cons is a version of the kind of gently curious questioning of beliefs (this is the "Cognitive" part of CBT). In the narrative work, these questions may come up spontaneously, but although acknowledging these questions the worker will try to keep to task - which at this stage is just the telling and re-telling of the story.

Further elements of Trauma-focussed CBT are recorded there separately.